Oral Cancer News
Compiled by The Oral Cancer Foundation

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Why are African-Americans more likely than Caucasians not only to be diagnosed with head and neck cancer, but also to die from the disease? While the answer isn’t a simple one, differences in lifestyle, access to care, and tumor genetics may be partly to blame, according to a new study from Henry Ford Hospital.

The study, which was presented September 14 at the American Academy of Otolaryngology – Head and Neck Surgery Foundation’s annual meeting in San Francisco, also found that African-Americans are more likely to be past or current smokers, one of the primary risk factors for head and neck cancer.

“We’re really trying to understand why African-Americans with head and neck squamous cell carcinoma do so poorly,” said lead author Maria Worsham, PhD, director of research in the department of Otolaryngology – Head and Neck Surgery at Henry Ford, in a news release. “Using a comprehensive set of risk factors that are known to have some bearing on the disease, we’re able to gain a better understanding of what contributes to racial differences and work to help improve patient care.”

This year alone, it’s estimated that 52,140 new cases of head and neck cancer will be diagnosed, and roughly 11,460 will die in 2011 from oral cavity and pharyngeal and laryngeal cancers, she and her team members noted.

African-Americans are more likely to be diagnosed with late-stage head and neck squamous cell carcinoma (HNSCC) and have a worse five-year survival rate than Caucasians. It’s unknown whether significant biological rather than socioeconomic differences account for some of the disparities in outcomes.

To get at the root of these differences, Worsham and her team used a large Detroit multiethnic group of 673 patients with HNSCC. Most notably, 42% of the study group was African-American.

The researchers took a broad approach to the study, examining many of the intertwined variables influencing health and disease to look for differences among African-Americans and Caucasians. In all, the study focused on 136 risk factors, including demographics (age, race, gender), smoking and alcohol use, access to care, and type of cancer treatment (radiation and/or surgery). Tumor characteristics, including stage, biology, and genetics, also were examined.

Among the study findings:

While 88% of African-Americans in the study had medical insurance, the majority had Medicare or Medicaid instead of private health insurance.

African-Americans also were more likely to be unmarried or living alone, both of which previous studies suggest have a negative impact on quality of life and survival.

In terms of cancer treatment, African-Americans in this study were more than two times more likely than Caucasians to receive radiation therapy. The study showed fewer African-Americans (43%) opted for surgery than Caucasians (49%).

African-American tumors were six to seven times more likely to present with lymphocytic response.

Compared to Caucasian tumors, African-American tumors were almost two times more likely to have loss of the cyclin-dependent kinase inhibitor 2A (CDKN2A) gene and gain of the small inducible cytokine A3 (SCYA3) gene. CDKN2A is important to cell cycle regulation, and the SCYA3 gene product has dual roles of tumor lymph node metastasis and local host defense against tumors in HNSCC.

A Georgia College student steps outside, pauses and inhales, filling his lungs with acetone, ammonia, arsenic, benzene, butane, formaldehyde, lead and turpentine – just 8 of the more than 50 carcinogens found in the average cigarette.

According to the Centers for Disease Control and Prevention, of the 46 million smokers in the U.S., college students are among the highest percentage of smokers. Almost 22 percent of adults ages 18-24 smoke, according to 2009 CDC data.

Their professors are not far behind them in their smoking addiction. According to the CDC data, almost 22 percent of people ages 45-64 are smokers. In 2009, the CDC found that adults in the Southeast were among the most prevalent smokers in the United States.

While there are no hard statistics for the percentage of students and staff that smoke at GC, it is not uncommon to see a familiar gathering of smokers sitting outside any of the dorms.

Lauren Luker, junior mass communication major, started smoking in order to get a break at her job as a server.

“You couldn’t have a break unless it was a smoke break,” Luker said.

Now, eight years later, Luker is worried about the health of her lungs and is planning on quitting after several previous failed attempts.

However, quitting such an addictive habit is not always easy, as Luker knows.

According to the National Institute on Drug Abuse, nicotine is as addictive as heroin and cocaine. Fortunately for GC students and staff who are interested in kicking their habit, there is a smoking cessation program held by GC three times a year.

“(The classes) are held once every fall, spring and summer,” Whatley said.

However, this free program is not very popular among students.

“We’ve only had one student complete (the smoking cessation program) in the last three years,” Whatley said.

While the smoking cessation program is not very popular among GC students, the FDA is beginning a new advertising campaign that has been popular in other countries, such as Australia and Canada.

According to the FDA, as of September 2012, all packages of cigarettes must show graphic images of the effects of smoking and bold text warning of the dangers of smoking.

The graphics range from a man smoking through a hole in his throat to a mouth riddled with sores and rotting teeth – the cruel effects of oral cancer.

According to the American Cancer Society, other countries have had a great success rate with this controversial method. A positive correlation has been shown between people becoming more aware of the harmful effects of smoking and choosing to quit.

The hope is that after being confronted with the grim side effects, such as oral cancer or death, smokers will be more motivated to cut down on their smoking habit or quit altogether.

Currently, smoking is responsible for 20 percent of deaths in the U.S., and is the leading cause of preventable death.

But the human body is resilient and begins to heal itself just minutes after the last cigarette is smoked.

According to the American Cancer Society, just 20 minutes after quitting smoking, blood pressure is noticeably reduced.

Twelve hours after a person quits smoking, the carbon monoxide level in their blood drops to normal.

At nine months, the smoker’s fatigue and shortness of breath decreases.

One year after quitting, an ex-smoker’s risk of heart disease is half that of a smoker.

Ten years after quitting, the death rate for lung cancer is approximately half that of a continuing smoker.

Although university denizens find themselves among the most prone demographics of smokers, they can breathe more easily knowing that GC provides help for those who need it.

Smokers who light up first thing in the morning have a higher risk of developing head and neck cancer than those who wait that little bit longer for their first cigarette of the day, a study has suggested.

A research team from the Penn State College of Medicine in America investigated whether nicotine dependence, as characterised by the time smokers take to have their first cigarette after waking, affects smokers’ risk of lung, head and neck cancers independent of cigarette smoking frequency and duration.

They analysed 1,055 people with head and neck cancers and 795 who did not have cancer, all of whom were cigarette smokers.

Individuals who smoked 31 minutes to an hour after waking were 1.42 times more likely to develop head and neck cancer than those who waited more than hour before having a nicotine fix.

Those who waited less than half an hour to have their first cigarette of the day were 1.59 times as likely to develop head and neck cancer.

According to Cancer, a journal of the American Cancer Society, the results of the study may help identify smokers who have an especially high risk of developing cancer and would therefore benefit from targeted smoking interventions.

Dr Joshua Muscar, lead researcher, said: “These smokers have higher levels of nicotine and possibly other tobacco toxins in their body, and they may be more addicted than smokers who refrain from smoking for a half hour or more.”

A vaccine that prevents cancer is the dream of just about every patient, doctor, and public health official. Therefore, hopes were quite high five years ago, when the U.S. Food and Drug Administration approved a vaccine to prevent human papillomavirus, or HPV, a sexually transmitted virus that causes almost all cases of cervical cancer.

But despite its clear efficacy, the vaccine has been something of a dud. According to a 2008 survey, only 34 percent of the target crowd, girls aged 13 to 17 years, had received it. The reasons for the slow uptake relate to generic vaccine issues (cost, pain, distrust) as well as a particular discomfort with this one, dubbed the “sex vaccine” by many conservatives, who object to it on the grounds that it somehow promotes licentious behavior (as if it were possible to make teenagers any hornier).

However, a new study presented at last week’s annual meeting of the American Society of Clinical Oncologists makes the vaccine look even more valuable. Though preliminary and still unpublished, these findings have the potential to finally shift the perception that HPV is a woman’s problem and convince parents to get their boys vaccinated against the virus, too.

The researchers make the most compelling case to date that HPV causes yet another malignancy—oropharyngeal cancer, a disease that affects men three times more often than women. (It’s a subcategory of “oral” or “head and neck” cancer, which also predominantly affect men.) Their work appears to have settled a debate that had been rattling on for a decade, ever since clinicians first noticed a change in the way oral cancer was behaving.

In the past, oral cancer had been a disease of drinkers and smokers—the poster child was Ulysses S. Grant, who died of the disease (and knew plenty about drinking and smoking). But in the 1990s, more and more cases were seen in nonsmokers, puzzling clinicians; furthermore, the tumors were found in a different area of the mouth—the oropharynx (or front of the mouth), especially the tonsil and the base of the tongue. Previously, oral cancer tumors were mainly seen further back in the throat or near the voice-box.

So began a pursuit that proceeded along two lines of inquiry. First, the epidemiologists who track rates of cancer over time found an alarming rise in cancers of the tonsil and base of the tongue, with a simultaneous decrease in oral cancers found in the other, traditional smoking-related sites. Meanwhile, scientists found that many of the tumors in nonsmokers had HPV in them. Though an intriguing finding, this isn’t the same as saying that HPV was causing the cancer. Perhaps HPV had been in oral cancers all along, and no one had thought to look.

So that’s exactly what the current investigators did. The researchers, from the National Cancer Institute, examined 271 oropharynx tumor samples collected between 1984 and 2004 using new, super-sensitive molecular detection methods that were not available in the ’80s and ’90s. Bingo: They found a four-fold increase in HPV-positive tumors over the 20 years. (HPV was in 16 percent of early samples, compared to 73 percent of recent ones.)

In many people’s view (including mine), this new study nails HPV as the cause of many oral cancers. At the same time, it makes a mighty persuasive case for boys to get vaccinated against HPV. This is a good thing: If vaccination rates are low for girls, they’re invariably lower for boys, who until now had no logical (read: selfish) reason to get the expensive series of shots. (The FDA approved the vaccine for boys in 2009, but wimpily, without any strong recommendation to actually administer it.) OK, sure, it prevents venereal warts, which are no fun. But warts may not seem like such a big deal to a harried mom who has to drag her little darling to the pediatrician three times in six months to ward them off. Now that HPV has been convincingly linked to oral cancer in men, parents have a much more compelling reason to get Junior vaccinated than altruistic concerns about the health of any future female sex partners he may have.

There is one large caveat to this dream of a healthier tomorrow. There are some 20 different HPV strains that can lead to cancer, and while current vaccines prevent the ones that cause 70 percent of all cervical and the majority of oropharyngeal cancers, they’re not completely comprehensive. (To make a vaccine effective for all strains of HPV—including the 100 or so that don’t cause cancer but may cause warts and other skin problems—you’d need a syringe the size of a milk carton.) So parents should know that getting their sons and daughters these shots won’t guarantee that they will never develop HPV-related cancers.

But even with this limitation, the potential benefit of the vaccine is quite large. Cervical cancer is the most common cause of cancer death in women in many developing countries; in the United States, Pap smears and early treatment have sharply reduced the impact, though it still affects 12,000 women a year and kills 4,000 (PDF). Meanwhile, head and neck cancer is diagnosed in 36,000 people (mostly men), killing 8,000, making it the eighth-most-common cancer for men—a figure that will continue to rise as the impact of HPV infection is manifest. Indeed, the NCI researchers projected that, given the current increase in cases, HPV-related oropharyngeal cancers would be more common than cervical cancer by the year 2020.

If the past is any indication, though, I suspect a more eyebrow-raising angle will overshadow this important public health story. Since the link between HPV and oral cancer was first floated 10 years ago, the media has tended to focus on just one aspect—the possible connection between oral sex and the rise in oropharyngeal cancers. However, there’s no definitive evidence yet of a causal relationship between the activity and the disease. That’s not to say that people shouldn’t exercise a reasonable amount of caution when having oral sex. But when popular opinion (particularly in matters sexual), wags science, no one benefits.

It’s easy to see why the notion that oral sex can give you cancer is so attractive. It makes for an irresistibly lurid headline, of course, and it appeals to the secret Victorian hidden less or more deeply in all of us. (Everything fun has a price—everything!) And to be fair, the circumstantial evidence is compelling. It’s well understood that HPV is transmitted through other kinds of intimate contact, such as vaginal sex. HPV seems to grow quite well on mucous membranes, those nonskin tissues that line the mouth, nose, vagina, anus, and a few other anatomic areas, and which may touch quite a bit during oral sex.

As an explanation for the uptick in oropharyngeal cancers, though, oral sex has one glaring problem: HPV-positive head and neck cancer is, inexplicably, a guy’s disease. If oral sex were driving the issue, wouldn’t we see a commensurate rise in HPV-positive tumors among women? Unless the announcement was screened out by my workplace email filter, I don’t think anyone has demonstrated that cunnilingus is being practiced more often than fellatio.

Furthermore, many people with HPV-positive head and neck tumors deny having had much oral sex. According to a 2010 review of several studies on the topic, more than half of such patients reported five or fewer lifetime oral sex partners, and 8 to 40 percent said they had never had oral sex.

Finally, the argument that oral sex is driving the rise in these cancers carries the implicit suggestion that oral sex patterns of recent years vary considerably from previous generations. Among the many things we don’t know about our forebears, what they did and didn’t do in the bedroom surely ranks near the top. And it always is a bad wager to bet against the likelihood that everyone, in every decade, was having all types of sex, and as often as possible.

To be fair, the oral sex angle does make one important contribution to the efforts to control HPV: It gets people’s attention. As the titillated masses wait for the truth to emerge, here’s hoping they do the right thing—and take their kids to the corner pediatrician to get vaccinated.

A device that emits a blue light is giving patients undergoing surgery for oral cancer a fighting chance at survival and Canada is at the forefront of research that could have a global impact, researchers say.

Doctors and scientists in nine Canadian cities began testing the tool last September as part of a five-year study on 400 patients who are suffering from cancer that has afflicted their tongue or other parts of the mouth.

The hand-held fluorescence visualization tool allows surgeons to see cancer cells that can’t be detected by conventional white light so they can remove the affected tissue and prevent the disease from recurring.

Balvir Dhadda, 47, thought she’d been given a death sentence when she was diagnosed with the deadly disease four years ago after developing a sore underneath the left side of her tongue.

“When I got diagnosed, I thought `That’s it.'”

But Dhadda credits the blue light device for saving her life.

“This was the tool used on me, and the rest is history,” Dhadda said Thursday.

The tool ensured doctors removed only the tissue that was cancerous, rather than the usual practice of removing parts that might potentially be.

“I think it was a major factor in the time it took me to recover afterwards,” said Dhadda, of Surrey, B.C.

Miriam Rosin, the principle investigator of the study, said the blue-light tool developed at the BC Cancer Agency had been used to detect lung, cervical and skin cancers but is being used surgically for the first time for oral cancer.

Rosin said surgeons use the device to see cancer cells they’d otherwise miss and leaving normal tissue behind.

“When surgeons treat the disease, they catch everything that’s immediately apparent but it’s well known that a lot of the disease is scattered across the mouth,” she said.

“We showed that we could significantly stop recurrence rates,” she said of an initial study two years ago on 20 patients with early-stage oral cancer.

Rosin said the results were so promising that for the first time, teams of experts including surgeons, pathologists, research staff and scientists were brought together in nine cities across Canada to conduct the current study, which is funded by the Terry Fox Research Institute.

“It’s groundbreaking because if it works the way we hope it works, it’s going to have a big impact in the way we treat the disease and the assurance is from surgeons and from the professional societies that this will change clinical practice,” she said.

“This is a big first and the whole vision of everybody is, `Let’s get the data that will support a change in practice. It’s a major thing for Canada,” she said of the study being conducted in Vancouver, Toronto, Montreal, Ottawa , Halifax, Edmonton, Calgary, Winnipeg and London, Ont.

Every year, about 3,400 Canadians are diagnosed with oral cancer, which is deadly once it spreads to the neck, throat and lymph nodes.

“With oral cancer, about one in two people will die before five years so it’s one of the worst cancers,” said Rosin, who is also a senior scientist and director of the BC Cancer Agency’s oral cancer prevention program.

The cancer typically strikes heavy smokers and drinkers, although patients like Dhadda who don’t fit that category are being diagnosed more frequently, Rosin said.

If the study shows the blue light device to be effective, the goal is to immediately start disseminating it across Canada and eventually the world.

To help with that effort, Simon Fraser University health scientist and medical anthropologist Kitty Corbett will work with the study teams to transfer their knowledge into hospitals and doctors’ offices.

Corbett said scientists often mention in the last paragraph of published research papers that a particular study has the potential to change clinical practice, but it’s up to other professionals to make the change.

The transfer of research into real-life policies is complex and takes a long time, she said, adding that working with surgeons during the study will help her understand the challenges they face in their jobs.

“If we build this kind of partnership from the get-go we should end up getting a lot of these answers in place,” said Corbett, adding the study participants would train others in using the blue light tool.

May 19, 2011 — Cigarette manufacturers have deceived consumers about the risks of their products for years, and remedial actions are needed so consumers can make informed decisions about the products they purchase, according to researchers from the Roswell Park Cancer Institute (RPCI).

The researchers evaluated the messages that cigarette pack labels convey to smokers and nonsmokers, and their findings will be published in three studies in an upcoming issue of the American Journal of Preventive Medicine (June 2011, Vol. 40:6, pp. 674-698).

“Tobacco companies have used attractive packaging and persuasive images to market their products for decades,” said lead author Maansi Bansal-Travers, PhD, a behavioral research scientist at RPCI, in a press release. “These studies support efforts by the [U.S. Food and Drug Administration] to regulate cigarette pack labeling.”

Tobacco manufacturers have effectively used cigarette pack design, colors, and descriptive terms to create the illusion that filtered and so-called light/mild cigarettes are safer than unfiltered and full-flavor cigarettes, when this is not the case.

Beginning in June 2010, regulations contained in the Family Smoking Prevention and Tobacco Control Act have prohibited tobacco companies from using descriptive terms such as “light,” “mild,” or “low” in advertising and on cigarette packaging.

“While the removal of these obviously misleading terms was a good first step, we discovered that cigarette manufacturers have circumvented the regulation by using different terms such as ‘gold’ and ‘silver’ and changing the colors on packs to continue to mislead consumers about their products,” Bansal-Travers said.

The first study, titled “What Do Cigarette Pack Colors Communicate to Smokers in the U.S.?” found that both colors and descriptors are perceived by smokers to communicate health-risk information. The authors recommend that color coding be restricted in the same way that descriptors have been to reduce consumer misperceptions.

A second study, “The Impact of Cigarette Pack Design, Descriptor, and Warning Labels on Risk Perception in the U.S.,” found that larger graphic health warnings that convey negative messages are the most effective in communicating health risks to adults and that packs with descriptors such as “smooth” or “silver,” or in specific colors, misleadingly conveyed lower health risks to consumers. Manufacturers should be barred from using any labeling that might be misperceived by consumers, and all cigarettes should be sold in standardized plain packs, the authors concluded.

The third study, “Correcting Over 50 Years of Tobacco Industry Misinformation,” analyzed proposed corrective statements required by U.S. federal court in the Department of Justice case against cigarette manufacturers. The authors found that the proposed corrective statements were effective in correcting false beliefs about smoking and health. The authors also recommend that these statements be printed on cigarette packs and at the point of sale.

“These studies reveal how consumers are likely to respond to government-mandated changes in package labeling and offer insights and recommendations about how to correct decades of misleading product marketing, so that consumers can make more informed choices about the products they purchase,” concluded K. Michael Cummings, PhD, chair of the department of health behavior at RPCI.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

Right now, there are 1.2 billion smokers worldwide, and 5 million of them die each year. Some experts say that death rate could double by the year 2030. While 1 million smokers now hope E-cigarettes cure their addiction, one academic says the data doesn’t add-up.

Hollywood got Freda Souligny smoking at just 13.

“It was a killer,” Souligny told Ivanhoe.

Now 81, she had a pack-a-day habit for 61 years. She stopped when emphysema led her to electric cigarettes two months ago.

“I didn’t feel this horrible withdrawal,” Souligny said.

Battery-operated, they deliver nicotine vapor through an adjustable cartridge and cost about 60 bucks to start. Souligny kicked her habit by slowly cutting the nicotine dose over several weeks. However, Professor Tom Eissenberg says E-cigs are misleading.

“We wanted to know if they really delivered nicotine — one of the things they’re supposed to do — if they really produce some of the same effects as a tobacco cigarette,” Eissenberg, Ph.D., from Virginia Commonwealth University, told Ivanhoe.

A pair of studies found while real cigarettes deliver nicotine, E-cigs do not — despite claiming to do so.

“Neither of them delivered nicotine, which was surprising, because that is, in fact, exactly what they are supposed to do,” Eissenberg said.

He says smoking an E-cig is just like puffing on an unlit cigarette. There’s no nicotine, no tobacco … nothing.

Souligny doesn’t agree.

“Well, you have to tell me what changed my life,” Souligny said. “It wasn’t medication, because I didn’t take medication.”

The studies do say E-cigs can cut the urge to smoke by nearly half, so Souligny’s mind may be tricking her body, but she doesn’t care.

“To me, it’s just been miraculous,” Souligny said.

Professor Eissenberg says E-cigs may indeed be a key tool in helping people quit standard cigarettes. Still, he’s calling for tighter government control of the products. The reason: if they don’t do what they claim to do, consumers have the right to know.

If you’re keeping score, here’s even more evidence that HPV causes oral, head and neck cancers and that vaccines may be able to prevent it.

Researchers studying the human papilloma virus say that in the United States HPV causes 64 percent of oropharynxl cancers. In the rest of the world, tobacco remains the leading cause of oral cancer, Dr. Maura Gillison of Ohio State University told a meeting of the American Association for the Advancement of Science this past weekend.

And the more oral sex someone has had — and the more partners they’ve had — the greater their risk of getting these cancers, which grow in the middle part of the throat. “An individual who has six or more lifetime partners — on whom they’ve performed oral sex – has an eightfold increase in risk compared to someone who has never performed oral sex,” she said.

The recent rise in oropharnx cancer is predominantly among young, white men, she noted, though she says no one has figured out why yet. About 37,000 people in the United States were diagnosed with oral cancer in 2010, according to the Oral Cancer Foundation.

People with HPV-related throat cancer are more likely to survive their cancer than those who were heavy smokers or drinkers, the other big risk factors.

The message may be more critical for teens according to Bonnie Halpern-Felsher, professor of pediatrics at the University of California, San Francisco. She has studied 600 adolescents over 10 years and found that oral sex is much more common than vaginal sex and that “teens don’t consider oral sex to be sex,” that they think “it’s not that big a deal.” She adds: “Parents and health educators are not talking to teens about oral sex. Period.”

Worldwide, HPV-related cancers seem to be increasing. Gillison said that Swedish researchers looking back over 30 years found that 23 percent of oral cancer tumors in 1970 were positive for HPV, but in 2005, that number had risen to 93 percent.

The British newspaper The Guardian noted that Gillison said that “every birth cohort appears to be at greater risk from HPV and oral cancers than the group born before them.”

Over the past five years, health officials have been urging parents to make sure their daughters are vaccinated against HPV to help prevent cervical cancer. But these new results suggest that young men could also benefit from vaccination, though the costs would be substantial.

While none of the researchers could say definitively that the vaccines against HPV, Gardasil and Cervarix, would prevent throat cancer, they thought it could was reasonable to think the vaccine could reduce risks as well.

Note: Some of Gillison’s research is funded by Merck, the pharmaceutical company that makes Gardasil.

A Florida Supreme Court ruling that threw out a $145 billion award against cigarette makers is biting Big Tobacco back, making it dramatically easier for thousands of smokers to sue and turning the state into the nation’s hot spot for damage awards.

The 2006 ruling has helped generate more than $360 million in damage awards in only about two dozen cases. Thousands more cases are in the pipeline in Florida, which has far more smoking-related lawsuits pending than any other state.

Though the justices tossed the $145 billion class-action damage award, they allowed about 8,000 individual members of that class to pursue their own lawsuits. And in a critical decision, they allowed those plaintiffs to use the original jury’s findings from the class-action case.

That means the plaintiffs don’t have to prove that cigarette makers sold a defective and dangerous product, were negligent, hid the risks of smoking and that cigarettes cause illnesses such as lung cancer and heart disease. The plaintiffs must mainly show they were addicted to smoking and could not quit, and that their illness – or a smoker’s death – was caused by cigarettes.

Jurors have sided with smokers or their families in about two-thirds of the 34 cases tried since February 2009, when the first Florida lawsuit following the rules set by the Supreme Court decision went before a jury. Awards have ranged from $2 million or less to $80 million, though tobacco companies are appealing them all.

The successes by smokers or their survivors in Florida compares with just six wins between 1996 to 2006 in Florida. Before 1996, individual smokers won only a handful of cases nationwide.

Tobacco company lawyers insist the process is rigged.

“We believe the trial courts have used trial plans that are so fundamentally unfair they violate due process and Florida law,” said Murray Garnick of Altria Client Services, which represents Altria Group Inc. subsidiary Philip Morris USA. “Each case must be judged on its own facts.”

The tobacco companies, however, have lost their first appeal over how Florida courts are handling the cases. The state’s 1st District Court of Appeal ruled against R.J. Reynolds Tobacco Co. in December, upholding a $28.3 million verdict for a dead smoker’s wife and endorsing the way trial judges have interpreted the state Supreme Court’s decision.

Steven J. Hammer, an attorney whose Fort Lauderdale firm is handling hundreds of smoker lawsuits, said the Florida cases have changed the balance of power in the courtroom because tobacco companies are prevented from arguing that their products aren’t necessarily dangerous and addictive.

“As a result, the whole story is being told: how they lied to the public, all for the almighty dollar,” he said.

One of Hammer’s clients, 93-year-old Leon Barbanell, won a nearly $2 million verdict against Philip Morris USA for the 1996 death of his wife of 56 years from lung cancer. Shirley Barbanell smoked up to two packs of Chesterfields, Marlboros and other cigarettes a day for 50 years and could not quit despite many efforts, her husband said. He’s worried that, because of appeals, he may die before he ever sees a cent.

“I miss her company every day,” Barbanell said. “She was always there for me. We went everywhere together.”

A jury in northern Florida’s Levy County granted the largest award issued under the Supreme Court ruling, $80 million, to the daughter of a man who died of lung cancer in 1996 after smoking for decades. Others awarded $46.3 million for a widow in the Gainesville area who lost her husband to lung cancer; and almost $39 million for a Fort Lauderdale woman suffering from advanced emphysema after smoking Philip Morris’ Benson & Hedges brand for years.

The tobacco companies point out that during one stretch in 2010 they prevailed in eight of nine cases, although the trend later was reversed. Attorneys said cigarette makers often win when it is difficult to prove that cigarettes caused a particular illness, or when jurors decide that people who smoke must take responsibility and assume the consequences.

“There are some jurors who are really opposed to the idea of someone who smoked bringing a case against the cigarette manufacturer,” said Keith Mitnick, an Orlando attorney who won a multimillion-dollar verdict against R.J. Reynolds in April. “In jury selection, we target that very question. It doesn’t take but one strong-willed juror to make the difference in the outcome.”

Tobacco companies’ recent setbacks are not limited to Florida:

– In Boston, a jury in December awarded $152 million to the estate and son of a woman who died of lung cancer in 2002. The lawsuit claimed that Lorillard Tobacco Co. hooked the woman on smoking after giving away free samples of cigarettes in the Boston housing project where she lived as a child.

– In Connecticut, U.S. Smokeless Tobacco Co., maker of Skoal and Copenhagen, agreed in December to pay $5 million to the family of a man who died of mouth cancer in what was believed to be the first wrongful-death settlement won from a chewing tobacco company.

– Also in December, Minnesota’s appeals court allowed a class-action case to continue for people who claim Marlboro Light cigarettes, made by Philip Morris, were marketed as supposedly safer to smoke using false advertising and consumer fraud. Philip Morris is appealing that decision.

If the losing trend and multimillion-dollar verdicts continue, some legal experts said the tobacco companies may rethink their long-standing policy against settling the smoker lawsuits.

“When we get to the point that plaintiff verdicts are upheld, with the industry looking at thousands of additional trials and expenses, they would weigh all of that together and possibly settle later down the road,” said Edward Sweda, senior attorney for the Tobacco Products Liability Project at Northeastern University law school in Boston.

Lawsuits will likely end up before the U.S. Supreme Court before that has a chance of happening.

“We have a strong legal and factual basis to fight each of these cases. We will fight every adverse decision against us,” said Garnick, the Philip Morris attorney.

The tobacco companies have a long history of doing just that, but they have settled in the past. The biggest came in 1998, when four cigarette makers and 46 states settled for $206 billion a series of lawsuits claiming that smoking drove up public health costs.

In 2006, a federal judge in Washington, D.C., found the six largest tobacco companies guilty of racketeering and fraud for deceiving the public about the dangers of smoking.

The ruling, upheld by an appeals court in May 2009, requires that cigarette manufacturers change the way they market cigarettes. The requirements, since adopted by the U.S. Food and Drug Administration, ban labels such as “low tar,” “light,” “ultra light” or “mild,” since such cigarettes have been found no safer than others.

The ruling was appealed to the U.S. Supreme Court, but the justices declined to hear it.

CHAPEL HILL — So, now R.J. Reynolds Tobacco Company wants to help smokers “break free” from tobacco? That statement should make parents, health care providers and smokers nervous.

Last month, Reynolds promoted its Camel Snus (a “spit-free” tobacco pouch) with advertisements in national magazines that read “If you’ve decided to quit tobacco use, we support you,” under a large “2011 Smoke-free Resolution” banner. Reynolds then offered its smoke-free snus as the solution.

For smokers, the majority of whom try to quit every year, the message should be to quit tobacco use, not to substitute one form of cancer for another. No safe form of tobacco use exists. Smokers who try tobacco snus products are at high risk of becoming addicted to both cigarettes and snus, thus continuing or even adding to their risk for lung, bladder, breast, cervical, oral and pancreatic cancer.

In addition to running these misleading ads in People, Time and Rolling Stone, R.J. Reynolds is continuing a long-standing practice of targeting vulnerable populations such as young people, African-Americans and gays and lesbians.

Last year, research in the medical journal Pediatrics implicated Reynolds’ “Camel No. 9” campaign in an increase in smoking among young teenage girls.

The tobacco industry has long targeted African-Americans by focusing on marketing and so-called “corporate social responsibility” strategies to buy favor with civil rights organizations. Researchers at the University of California, San Francisco estimated that the approximately $25 million in tobacco industry corporate philanthropy that funded African-American community groups, when divided by the number of premature deaths from tobacco in black communities, meant that each African-American death was traded for $555 in corporate support.

In December, a court in Massachusetts found Lorillard, Inc., liable fortargeting black teenagers with free samples of menthol cigarettes.

Now, Reynolds has begun targeting gay and lesbian newspapers across the country.

Our own research at UNC-Chapel Hill shows that gays and lesbians are 50 percent to 100 percent more likely to smoke and thus to die much earlier from tobacco-related diseases. We recently conducted surveys in gay and lesbian bars and Pride Festivals in West Virginia in which 45 percent of those surveyed reported using a tobacco product. These rates of tobacco, cigarettes and snus use are alarming and likely even higher among transgender populations.

Researchers have documented that industry-designed youth prevention programs actually increase youth susceptibility to trying cigarettes. New campaigns that promise a smoke-free life by promoting other addictive tobacco products will likely keep more people addicted to tobacco.

Smokers who want to quit for real should talk to their health care providers, make a quit plan and call the free Quitline at 1-800-QUITNOW or visit www.BecomeAnEX.org.

The evidence is clear: advertisements from the tobacco industry sell death, half-truths and promote health inequalities. Federal judges have let stand industry racketeering convictions resulting from conspiracy to hide health consequences of smoking. Smokers’ resolutions to quit should not be co-opted into deeper addiction by industry advertising.